SEATTLE -- Pediatricians may be more reluctant to disclose an error that's not immediately apparent to a child's family, researchers reported here.

Action Points

Explain to interested patients that pediatricians were more likely to disclose an error that's apparent to a child's family than a less obvious error.

SEATTLE, Oct. 6 -- Pediatricians may be more reluctant to disclose an error that's not immediately apparent to a child's family, researchers reported here.

More than twice as many pediatricians would disclose a conspicuous error to a parent than would disclose a less obvious one (73% versus 33%, P<0.001), David Loren, M.D., of the University of Washington School of Medicine, and colleagues reported in the October issue of Archives of Pediatrics and Adolescent Medicine.

"Considerable uncertainty remains among pediatricians about when and how to disclose an error," the researchers wrote, citing recent studies that have found a "disparity between patients' desire for open and honest communications and what physicians actually do when faced with disclosing an error."

To analyze what pediatricians do about disclosing errors, the researchers surveyed 205 physicians between July 1, 2003 and March 31, 2004. Respondents randomly received one of two scenarios describing a serious error and were asked whether the family should be told about the error.

They were also asked a series of questions about how a conversation about the error would go and each question had a scripted response that reflected a degree of disclosure -- none, partial, and full.

In one scenario, a child was admitted to the intensive care unit after an insulin overdose; in the other, a child was hospitalized with bacteremia after the pediatrician failed to follow up on a lab test. The latter error was considered to be less apparent to the parents of the child.

Combined scores for the two scenarios showed 53% percent of pediatricians would definitely disclose the error, followed by 40% who said they would probably disclose it, and 7% who said they'd admit it only if asked by the parent.

When choosing a disclosure statement, 59% of physicians would opt for one that provided an explicit description of how the error occurred, and 40% said they would want to include why the error occurred.

Just over a quarter (26%) would also include an explicit apology that acknowledged causing harm to the child, and 50% would discuss plans for preventing future recurrences of the error.

Previous experience reporting a serious error to a family increased the likelihood that a pediatrician chose a disclosure statement with a detailed explanation of how (OR 3.10, 95% CI 1.7 to 5.8) and why (OR 2.03, 95% CI 1.1 to 3.6) the error occurred.

But previous training in error disclosure didn't increase the likelihood that the scenario error would be disclosed (OR 0.72, 95% CI 0.40 to 1.30).

When the two scenarios were analyzed separately, those who had to report the insulin overdose scenario were more likely to disclose the error to a parent and to provide full details about what happened than were those with the less obvious error (60% versus 32%, P<0.001).

They were also more likely to apologize for the harm caused to the child (33% versus 20%, P=0.04), but less likely to explain why the error occurred (31% versus 50%, P=0.02), the researchers said.

The researchers said this "marked variation" in intention to disclose the errors and also in what to include in the disclosure statement suggests the need for "quality improvement in error disclosure, specifically in the development of safe disclosure practices and the promulgation of professional guidelines and standards."

At the same time, the researchers wrote that error disclosure conversations are "among the most challenging conversations a pediatrician can experience."

Children are seen as more helpless than adult patients, for example, so pediatricians may face more self-recrimination in disclosing an error to the family.

Also, the statute of limitation for harm to a child is notably long and 34% of all survey respondents believed it was very likely they would be sued because of the error, with those given the apparent error scenario being far more concerned (50% versus 19%, P<0.001).

Although some hospitals, pediatric medical centers, and professional physician organizations have adopted error disclosure policies, the researchers said graduate and undergraduate medical education programs need to integrate error disclosure training into their curriculum.

The authors acknowledged that their study was limited by self-reported data, lack of generalizability, and the fact that respondents may have been influenced by the social desirability of their answers.

The study was supported by grants from the Agency for Healthcare Research and Quality, the St. Louis Children's Hospital, and the Seattle Children's Hospital and Regional Medical Center. One co-author was supported by the Greenwall Foundation Faculty Scholars Program.

The authors reported no financial conflict of interest disclosures.

Reviewed by Robert Jasmer, MD Associate Clinical Professor of Medicine, University of California, San Francisco

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